Friday
Aug152014

Ten Things to Know About Ebola Today:

Clive Riddle, August 15, 2014

While Ebola is only rampant in Africa, cases are now out-migrating, and Ebola is finally starting to get the increased  attention of the world it needs.  For those of us half a world away, we typically want to condense this information down to how it might ultimately indirectly or directly affect us. Unfortunately, some of that attention is overly shaped by fear, misinformation or even political agendas.

The CDC is a great resource site on Ebola Hemorrhagic Fever ,  including Ebola Virus Disease Information for Clinicians in U.S. Healthcare Settings.  NPR has a post today interviewing Jeanine Thomas, on why the Ebola decision has relevance for the U.S. health care system.  Much of the dilemma in West Africa is due to their lack of healthcare resources compared to more industrialized nations, as discussed in a Science Daily article posted yesterday, Ebola outbreak highlights global disparities in health-care resources, which pulls from NIH and New England Journal of Medicine content.

Perhaps a best first step for non-clinicians in the business of healthcare, is to become more conversant in the current state of affairs for Ebloa. As Lee Norman, MD, chief medical officer for The University of Kansas Hospital, reminds us, “the current Ebola Virus Disease is the deadliest on record but it is important to understand key elements of this virus. He and the University of Kansas Hospital have just released an excellent summary in the regard: 10 things to know about Ebola, we’ll repeat in its entirety:

  1. Cases Are Out-Migrating From Africa: This is happening due to the fact that infected or ill people are traveling out of those countries in Africa with Ebola outbreaks. Cases found outside of Africa may likely go up as the number of people leaving outbreak areas increases when aid-workers and others return to their home countries.
  2. No Cases of Human-to-Human Transmission Outside of Africa: There has been no human-to-human or other transmission to humans outside of Africa.
  3. Ebola Is Not Transmitted By Air, Only Via Bodily Secretions: Ebola is not respiratory, so it is not transmitted through coughing or breathing. These infections are occurring because of people who are exposed to bodily fluids of infected individuals.
  4. Ebola Is Not The Most Infectious Disease: As infectious diseases go, Ebola virus isn't inherently the most infectious nor is it the least infective from person-to-person. Measles and chickenpox, for example, are easier to spread. So are influenza and MERS.
  5. High Mortality Rates Due to Geography: The mortality rate is quite high in Africa Ebola cases, partly because of the chaos, instability, and unrest of the governments there, and very directly related to the fact that their access to standard treatment supplies (IV solution, tubing, syringes, and protective equipment) is not universally available. Ebola cases identified and treated in westernized nations, and those with modern infection control practices, will have a much lower rate than those seen in most African regions.
  6. Likelihood of Breakouts In Areas Outside of Africa: Meticulous infection control practices in modern hospitals will make it more unlikely that human-to-human transmission will occur in these settings. While expensive and advanced bio-containment units provide the highest level of infection control, it is unlikely that these units will be widespread throughout the world.
  7. No Approved Immunizations and Treatments: There are no approved immunizations to prevent Ebola virus infection. There are no approved treatments for Ebola virus infection. There are experimental antibody treatments, as well as an antiviral medication not approved for Ebola. But whether either or both are safe or effective for widespread use is not known. "Compassionate use" or "experimental use" of the above treatments is tempting, because no targeted, specific "conventional treatment" exists. But widely adopting experimental, unproven medications as "the new conventional therapy" has its own difficulties: Is it safe? Is it effective? Is it costly? Are there unanticipated "down-sides" to using them? A WHO ethics panel has given the go-ahead for this, something it has never done before.
  8. How Animals Play a Role: The non-human vectors that can harbor Ebola virus (fruit bats, non-human primates) are widespread in areas far removed from Africa. As such, it bears watching whether those vectors begin to harbor the virus. The WHO has an excellent map showing the parts of the world with these vectors.
  9. Alert Levels: The WHO and CDC both recently increased their respective alert levels. State and local health departments throughout the U.S. and world will certainly seek guidance as to the adoption of best "local practices" to guide hospital and care providers. The guidance by the CDC as to how to manage exposed individuals and those who might be incubating the infection are quite specific and helpful. They will certainly change as time goes on.
  10. What We Don't Know About Ebola: There are things unknown about Ebola. For example:
  1. Can a person have had a low-level infection and not know they ever had it? Probably, based on serum testing.
  2. Does a person who has had it and survived develop lifelong immunity? That is unknown at this point. The various strains of Ebola are enough different antigenically that there may not be cross-immunity.
  3. Is there such a thing as a "chronic carrier state" in humans where a person can shed the virus and be infectious for a long period of time, even when they themselves have no illness or symptoms? That is also unknown at this point.
Tuesday
Aug122014

The $10 Billion Search for Healthcare Innovation

By Claire Thayer, August 12, 2014

The hunt is on for the discovery of innovative ideas to change the delivery of health care at all levels.   Kaiser Health News published a great summary of this massive quest in this article: Washington's $10 Billion Search For Health Care's Next Big Ideas.  Funded by the new health care law, experiments are taking place in every state in the country with oversight provided by the newly created Center for Medicare and Medicaid Innovation.  Kaiser Health News tells us that the center’s ten-year, $10 billion budget is the largest ever devoted to transforming care. In several states the office is working to overhaul medicine for nearly all residents — not just those with government Medicare and Medicaid coverage.

In addition to seeking out new payment and service delivery models, Congress has defined – both through the Affordable Care Act and previous legislation – a number of specific demonstrations to be conducted by CMS and categorizes these Innovation Models into seven areas:

  • Accountable Care
  • Bundled Payments for Care Improvement
  • Primary Care Transformation
  • Initiatives Focused on the Medicaid and CHIP Population
  • Initiatives Focused on the Medicare-Medicaid Enrollees
  • Initiatives to Speed the Adoption of Best Practices
  • Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models

So far, the American Hospital Association has received $75.8 million towards it’s innovation initiatives, Johns Hopkins Univeristy has received $32 million, followed by several others receiving close to $25 million. Here’s a look at the Top 10 Recipients of the new Innovation Dollars:

week, HealthSprocket, the home for healthcare lists of all kinds, featured a couple of its recent lists on health care innovation:

If you’re looking for an easy way to stay current on healthcare innovation trends and initiatives, Health Policy Publishing has a new monthly newsletter, Healthcare Innovation News, dedicated solely to this topic, with feature articles contributed by leading national experts and executives in the field; Thought Leader insights; Industry Briefs; profile of a key individual involved with healthcare innovation initiatives; plus more.

Readers can get a free sample issue of the 12-page monthly Healthcare Innovation News publication here. And, if you’re simply wanting to stay in the loop on news and other general announcements pertaining to healthcare innovation, the bimonthly Healthcare Innovation Bulletin, also available from Health Policy Publishing, is accessible for free here, at any time.

Friday
Aug082014

Healthcare Workers Are More Confident About Their Prospects and the Future

by Clive Riddle, August 8, 2014

Randstad Healthcare, the national healthcare staffing firm, issues a quarterly report on healthcare workers’ confidence, conducted by Harris Poll, based on a survey of physicians, nurses, healthcare administrators and other healthcare professionals. Their just released second quarter 2014 report, which tells us that confidence is up for the second quarter in a row, and that healthcare workers had the highest level of confidence compared to all industries they track.

So what does that mean, that healthcare workers are increasing in confidence, are more confident than other workers, and what exactly is it that they are confident about?

The Randstad Healthcare Employee Confidence Index is a composite of various confidence measures via an online survey. The questions asked address their optimism regarding:

  • Their current employers’ outlook
  • Ability to find a new job
  • Likelihood of retaining existing job
  • Availability of other jobs
  • Strength of the economy

Key survey findings for healthcare workers included:

  • 71% have confidence in the future of their current employer, compared to 54% in the previous quarter.
  • 61% have confidence in their ability to find a new job (same as previous quarter)
  • 81% say it is not likely they will lose their jobs in the next 12 months, compared to 72 percent in Q1 of this year.
  • 28% are likely to look for a new job, compared to 33% in Q1, and 46% in Q4 2013.
  • 44% believe fewer jobs are available (compared to 48% previous quarter). 61% are confident they could find a job in the next 12 months.
  • 31% say the economy is getting stronger (compared to 29% previous quarter). 33% believe the economy is staying the same, and 37% believe it is getting weaker

Given all the political hubbub about the health care reform, it’s interesting to see that the pivotal ACA implementation year of 2014 actually brought a rise in confidence about job prospects, sector economic strength sand overall economic outlook, for those working directly in the industry. Perhaps this means that insiders don’t view the ACA as all doom and gloom.

Monday
Jul282014

Stopping on Green - Part 2

By Laurie Gelb, July 28, 2014

(Read the first installmant of this part post at Stopping on Green

 They Don’t Need No Satisfaction

If/as we rethink the adherence doctrine, with its emphasis on following bottom-up, and begin to consider supporting patients as largely self-informed deciders rather than passive consumers, to what corollaries does that lead?

Imperative 1: Consign “patient satisfaction” to the worm bin, and focus on beliefs and behaviors that drive optimal outcomes.  These are not the same thing. The latter arise from knowledge, experience and culture.  Patients aren’t satisfied, and can’t be, with a product that they hate, fear and continually shy from, unless they seek it out obsessively. They can be content with a single or series of encounters that turn out well, or “the best they could,” but we don’t want them to repeat the experience unless/until they have to, and indeed most of them [the worried well notwithstanding] don’t.  In what other category do we worry about who likes Dr. Smith how much while telling all and sundry that only 10% of the solution rests with Dr. Smith? And speaking of that 90%…

Imperative 2: Disease management that constrains high utilizers’ cost curves while optimizing the outcomes for which we all pay.  As we tell patients continually, but fail to support, we are actually not in charge of managing _their_ disease. To manage disease, we have to support patient, clinician and caregiver choices that avoid duplication, optimize coordination and keep health, not health care, as the laser focus. 

Imperative 3: An an e-health platform that supports all of the above.

E-health is only as good as the health part. It can’t be acceptable to cede EMR design to bureaucrats, process refinement to the business office and online functionality to Webmasters and programmers. 

Baby, I Don't Have a Car

Are we so focused on “consumer-driven care” that we have forgotten to provide consumers with a vehicle to drive toward optimal outcomes? 

We can’t decide to educate simply if/how/when to deviate from our bibles. It doesn’t pay enough for a layperson to learn our bibles. We have to educate in a different way — not simply about vocabulary and labels (the much-touted health literacy, which means about as much as knowing how to read an electrical schematic out loud). 

We can, as any educational program, provide healthcare intelligence. A consumer knows how to change a light bulb and if/how she can rewire a socket. In short, she knows what she doesn’t know. When we preach “follow,” many patients are honestly unsure as to the decisions they have the capacity to make. Then, when they call the overloaded provider’s office to ask about their current concern, we fail to address the underlying uncertainty about the parameters that prompted the question in the first place. Definitions of terms are not a substitute, since knowing what wiring is doesn’t mean I’m off to the junction box.  

The Long and Winding Road

I know that on some freeways, I can exceed the speed limit, but that still doesn’t mean I can drive 100 mph [an action whose commitment time is obviously greater, given braking distances, than if I were driving 70]. I also know that speed can mean death [stakes]. We know that we must never pour a drop of water into a gas tank, to take one example. Or that we should never pour gasoline onto a flame. We are not going to deviate “just a little” to see what happens. How did we internalize, abstract the rationale for these absolutes? We learned something from someone and/or tried it once, depending on our respective backgrounds.

Even when disease management prides itself on counseling small, incremental changes (bring an apple to work!), we are prescribing without insight on either side. If I hate apples, I’m left wondering if it’s comparable to bring a red plum, which I do like. Think about how long that simple question would take to answer via the Internet, and you have a glimpse of the muddy information overload around fruit. And everything else that might be healthy. 

Few of us eat eight servings of fruit and veggies daily (or know how many we ate). We can’t. When as content providers we offer these lofty outcome measures as “information,” consumers roll their eyes, laugh, sigh, blink, snort, tune out and move on. We want and expect them to deviate if/as necessary. In wellness, we encourage them to “do the exercise you like” and eat the greens they like, etc. We don’t say, eat a carrot salad every day because we know they wouldn’t, however good an idea it might be. Yet our most common copy point in command voice is, “Eat [insert official content here].” That implies a literal meaning, for something that we don’t mean. This language is worse than gibberish; it spawns opposition because it rings so far from the truth of daily living. 

Moreover, to apply information, you have to know something about evaluating information quality, relevance and how literally you need to take it.  How are we imparting a health care “street sense?” 

Teach Your Patients Well

If we put on a can of peas the bland, cover-the-bases “content” that populates the major health information sites, human knowledge of peas would come from experience and the “word on the street,” just as it does for other areas in which the “official voice” is seldom heard because it is too opaque. How much of what you know about street drugs comes from officialdom? Amazon can recommend, sales associates can counsel, but for health care, with far greater stakes, there’s canned risk assessments (scripted encounters, waiting room brochures, package inserts, click here for a percentage you’ll need the footnotes to understand). For the obese, the dyslipidemic, the diabetic, the hypertensive, the smokers, we’ve made a better path the ultimate cliché. 

For decades, we’ve said, “We need to teach people the principles of weight management,” while forgetting the public health 101 concept of self-efficacy. If they don’t believe they can’t do it, they won’t even try. Weight management and all the rest of the “good ideas” require a series of choices that many people don’t believe they have the wherewithal to undertake, particularly in the face of an increasingly contradictory evidence base that our nagging letters usually fail to acknowledge at all. We’re not having conversations, as occur whenever you chat with your mechanic; we’re lecturing, pretentiously, and everyone’s falling asleep, only to wake up when the EOB appears.

And then we have the “act as if” faction in our ranks. “Big change is the only way it happens!” Yes, big change can happen if/when someone is scared, cornered, bored, self-impatient, angry, sorrowful. But we’re being paid on outcomes. Can we bank on emotion to inspire often short-lived change? And change from what? Our baseline measurement system is hopelessly flawed. Surveys reveal “the right answer.” Focus groups are pay for-a-play. Claims data reflect reimbursement, less often reality. Medical charts reflect adversarial legal incentives and a shortage of time. Even “real dialogues” during outpatient visits vamp to the camera, and social media monitoring finds the outliers with lightning speed. The best evidence of the real you have at your disposal any time is looking at you in the mirror.

Tell Me Why

Our risk assessment tools don’t allow the patient to contribute the facts that s/he knows best. Clinicians use heuristics to document and chart. Most charted histories omit at least one potentially relevant condition, event or genetic predisposition; it was not on a form, and/or it was not discussed. Many patients also reveal “medical history fatigue” which constrains the completeness of any particular history, and patients who have seen their chart notes are also aware that not all the information they provide is captured, apart from the form itself.  

 Since our brains are small, our days short and we’re only human, just as we have to use heuristics (decision shortcuts) to make everyday decisions about which route to take to work or what to order for lunch, we use heuristics to prioritize, consider, make, avoid, deny, delay and simply tune out myriad health issues and choices.  We’ve failed miserably to convey stakes and commitment times in health care, a lack of knowledge that can only constrain optimal decision-making. If an alien from another planet watched TV or went online for a few minutes, who could blame him for thinking that allergies or erectile dysfunction must be the world’s worst plague? 

It's All in the Game

In short, instead of focusing on an illusory “healthy mindset” whose stock doctrines are breathtakingly obvious (don’t touch the hot stove, stop smoking and cut back on Twinkies), we can more productively allocate all the money spent on bland DM pap to upgrading to the decision support available for silk blouses and video games. 

This week’s stiff-upper-lip letter from a major network, syndicated by a major vendor: …”We understand that there are many reasons why you may not want to take your medication…if you have any questions or concerns, we encourage you to contact your doctor or local pharmacy.”  Talk about “information” that will never be [read or] used! Each two-page letter contains two sentences about the particular drug’s rationale and consequences for not taking it; the rest is unadulterated condescension. How recently was any of your communication…interactive? Inquisitive? Conversational? Brief? 

Direct education in decision-making requires not just doling out information, but encouraging its acquisition through other channels, preaching that it is best leveraged in combination and in understanding, not rote. And then, it falls to MCOs, agencies, clinicians, jurisdictions…anyone with skin in the game, to kick our cheerleaders off the field and start playing full contact football. Our opponents include disease, ignorance, fear, denial, poverty, hunger, addiction and crime. And they've got a large lead. 

Friday
Jul252014

Everything Everyone Had To Say About Halbig and King

By Clive Riddle, July 25, 2014

Much has been written this week about the two conflicting circuit court decisions regarding Affordable Care Act Exchange subsidies - The Halbig v. Burwell decision that found against subsidies for FFE states was celebrated as a decisive blow against Obamacare by opponents; and hours later the King v. Burwell decision that came to an opposite conclusion and dampened, at least a tiny bit, such celebrations.

So is the net effect of the two decisions cause for Much Ado About Nothing, or Much Ado About Everything? Browsing the blogoshpere and articles from major organizations, here’s a sampling of what everyone had to see about the state of affairs in the aftermath – with some of the rhetoric a bit over-caffeinated and some seemingly more balanced:

Given these were not SCOTUS decisions, the question is – what’s next? Margot Sanger-Katz of the New York Times answers that question in her article After Health Law Rulings, Here Are Possible Next Steps in which she spells out these scenarios and steps:

  1. All the judges on the D.C. Circuit could decide the Halbig v. Burwell case.
  2. The law’s challengers could ask the Fourth Circuit to reconsider King v. Burwell.
  3. Decisions will be issued by other courts.
  4. Either side — or both — could appeal the rulings to the Supreme Court. T
  5. The Supreme Court could decide the case.
  6. Congress could act.
  7. States could act.

A Kaiser Health News article, New Health Law Court Decisions Could Have Limited Political Impact counsels that the decisions aren’t going to turn mid-term elections on their head: “Political analysts say this week’s court decisions on the legality of tax subsidies for those obtaining coverage under the Affordable Care Act may not have a broad impact on this fall’s midterm elections. The decisions sent a mixed legal message, complicating the political message as well. One appellate court panel ruled the subsidies cannot be provided in the 36 states relying on the federal insurance exchange; the other ruled in favor of the Obama administration, saying Congress intended that the subsidies be available regardless of whether states operated their own insurance marketplaces. Political candidates as well as voters will have to wait until the outcome of appeals of the cases to know their impact. But that didn’t stop some politicians from trying to immediately exploit the issue.”

If you are looking for a nice in-depth discussion of the situation – consider giving Timothy Jost’s Health Affairs Blog that provides such coverage: Implementing Health Reform: Appellate Decisions Split On Tax Credits In ACA Federal Exchange. He writes in part: “The issue in the cases is this: The ACA authorizes the IRS to provide premium tax credits to individuals with household incomes between 100 and 400 percent of the federal poverty level who are not eligible for other minimum essential coverage (such as affordable and adequate employer coverage, Medicaid, or Medicare). Premium tax credits are, however, only available to individuals who purchase coverage through the exchanges. The ACA requests that the states establish exchanges, and sixteen states and the District of Columbia have done so. The ACA also, however, authorizes the federal government to establish exchanges in states that fail to set up their own exchanges. The federal government has done so in 34 states and is operating the individual exchange for two more. The IRS regulation allows premium tax credits to be awarded to eligible individuals in both states with state-operated exchanges and states with federal exchanges. Two subsections of the ACA, which describe how the amount of tax credits are to be computed and what months can be covered by tax credits, however, provide that tax credits are available for months in which an individual is enrolled in a qualified health plan “through an Exchange established by the State under 1311” of the ACA. The plaintiffs in the King and Halbig cases argue that this provision bars the IRS from issuing premium tax credits to individuals who enroll in qualified health plans through federal, as opposed to state-operated, exchanges.”

What are the stakes? Tim tells us “these cases, as well as two other cases pending in the federal district courts in Oklahoma and Indiana brought by the attorneys general of those states, have clearly been brought for a political purpose — to bring down the ACA.”

But the last word on this for today perhaps should belong to John Stewart, who Adrianna McIntyre notes in her Vox Healthcare Blog: Still confused about the latest Obamacare lawsuits? Let Jon Stewart explain (which includes the video clip) “Stewart commended the judges on getting past stop signs the morning of the decision. ‘Until the law expressly provides a 'go' sign, we can in no way ascertain the intent of the framers of the sign. Surely the people honking behind me appreciate the rigor of my judicial acumen.’